HomeMy WebLinkAboutCLEARVIEW LT 17Onsite File
Clearview
Lot 17
#015-242-56
Municipality of Anchorage
On -Site Water and Wastewater Section • (907) 343-7904 Page 1 of 2
ON-SITE WASTEWATER INSPECTION REPORT
Permit Number: OSP201019 PID Number: 015-242-56
Dwelling: ❑Q Single Family (SF) ❑ with ADU ❑ Duplex (D) ❑ Two Single Family Project: ❑ New X Upgrade
Name
Michael Miller & Julia Moore
ABSORPTION FIELD
❑ Deep Trench El Wide Trench ❑ Bed El Mound
Site Address
SiteA
Fstline Court
❑ Other
Phone
Number of Bedrooms
Soil Rating
Total depth from original grade
4
GPD/SFJ
Ft.
LEGAL DESCRIPTION
Depth to pipe invert from original grade
Ft.
Gravel depth beneath pipe
Ft.
Subdivision Block Lot
Clearview 17
Fill added above original grade
Ft.
Gravel length
Ft.
Township Range Section
Gravel width
Ft.
Beds: Number of Lines
Distance between lines
Ft.
SEPARATION DISTANCES
To
Septic
I Absorption
Lift Station
Holding
Sewer
Total absorption area
Number of trenches
Dist. between trenches
From
Tank
( Field
Tank
Line
Ftz
Ft
Well
102.4'
n/a
n/a
n/a
E
TANK ❑® Septic ❑ S.T.E.P. ❑ Holding ❑ Other
Manufacturer
Greer
Capacity
1250 Gal.
J
Surface Water
100,+
n/a
n/a
n/a
Material
Number of compartments
I
Lot Line
51.71'
n/a
n/a
n/a
NA
Plastic
2
Foundation
F22.11'
n/a
n/a
( n/a
LIFT STATION
Manufacturer
Capacity
i
Remarks
Gal.
Alarm location
Electrical installed by
PIPE MATERIAL House to tank 3034 Tank to
3034
Installer
drainfield
Ak Underground INC.
Drainfieid CO/MT 3034
Inspector Pannone Engineering
BENCH MARK (Assumed elevation) 1021.0 ft
Inspection
v, 5/18/20 5/18/20
Location and description
2nd
3rd 0'
House Garage FF
ON-SITE WATER AND WASTEWATER SECTION APPROVAL
Engineer's Stamp
Conditional Approval: Date
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Septic System
&UW0
Approved Date
Note: this approval does not include well permit requirements.
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REVISIONS
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Revt: 5/26 2020
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RECORD DRAWING P.O. BOX 1807 PALLIER, AK 89645
PHONE (907) 745-8200 FAX (907) 745-8201
CLEARVIEW L17
DRAWN MICHAEL MILLER & JULIA MOORE
7850 FROST LINE CT
SITE PLAN ANCHORAGE, AK 99507
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RECORD DRAWING P.O. BOX 1807 PALLIER, AK 89645
PHONE (907) 745-8200 FAX (907) 745-8201
CLEARVIEW L17
DRAWN MICHAEL MILLER & JULIA MOORE
7850 FROST LINE CT
SITE PLAN ANCHORAGE, AK 99507
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Revt: 5/26 2020
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MUNICIPALITY OF ANCHORAGE
On -Site Water &Wastewater Program
PO Box 196650 47OOElmore Road
Anchorage, Alaska S9S19-OO50 Phone: 04 Fax (907) 343-7997
Permit Number: OSP201018
Work Type: SapdcTankUpgnyde
Tax Code Number: 01524256000
Site Legal Address: CLE/\F(V|EVVLT 17 G:2740
Site Mailing Address: 7850FFlOSTLINECT, Anchorage
Owner: MILLER MICHAEL GMOOREJULIA
Design Engineer: PANNONEENGINEERING SERVICES
This permit hsfor the construction of:
Effective Date
Expiration Date:
Lot Size in Sq Ft:
Total Bedrooms:
2/13/2020
2/12/2021
0 Disposal Field 2Septic Tank [] Holding Tank [] Privy 13 Private Well 0Water Storage
All construction shall bainaccordance with:
1. The attached approved design.
2. All requirements specified in Anchorage Municipal code Chapters 15.55 and 15.65 and the State of Alaska
VVembowaber Disposal Regulations (18AAC72) and Drinking Water Regulations (18AAC80)
3. The wastewater code requires inspections during the installation. The engineer shall notify the Development
Services Department per AMC 15.G5. Provide notification bycalling (9O7)343 -7Q04(24/7).
4. From October 15 to April 15, a subsurface soil absorption system under construction during freezing weather
shall beeither:
a. Opened and Closed nnthe same day, or
b. Covered, sealed, and heated to prevent freezing
Received By: /4__Jrt�
Issued By: " G)VX
AlWul"p,
E!
UNIUPAUTY OF ANCHORAGE
Com unity Development Department
Phone: 907-343-7904
Development Services Division Fax: 907-343-7997
On -Site Water & Wastewater Program
ON-SITE SEWER/WELL PERMIT APPLICATION
Parcel I.D. 015-242-56
Property owner(s) MICHAEL MILLER & JULIA MOORE Day phone
Mailing address 7850 FROSTLINE COURT, ANCHORAGE AK 99507
Site address Same
Legal description (Sub'd., Block & Lot) CLEARVIEW L17
Legal description (Township, Range & Section)
Lot Size 49,435 Sq. Ft. Number of Bedrooms 4
APPLICATION IS FOR:
APPLICATION IS AN: TYPE OF DWELLING:
(® all that apply)
Absorption Field
❑
Initial ❑ Single Family (SF) ❑X
(w/wo ADU)
Septic Tank
❑X
Upgrade FX]
(D) El
Holding Tank
❑
RenewalDuplex
❑ Multiple Dwellings ❑
Privy
❑
'(SF and/or D)
Private Well
❑
Water Storage
❑
THIS APPLICATION INCLUDES A VARIANCE / WAIVER REQUEST FOR:
s
Distance:
I certify that the above information is correct. I further certify that this is in accordance with
applicable Municipal Codes.
(Signature of property owner or authorized agent)
Permit/Rush Fees: ot016 Waiver Fees:
Date of Payment: A.11-1a0a0 Date of Payment:
Receipt Number: C13rJ % Receipt Number:
Permit No. 05P26FD(q— Waiver No. 1
Permit App_-'- :• :�...c.
Municipality of Anchorage
On-site Water and Wastewater
REVIEWED FOR CODE COMPLIANCE
OSP201019, Rebecca Carroll, 02/13/20
Municipality of Anchorage
On-site Water and Wastewater
REVIEWED FOR CODE COMPLIANCE
OSP201019, Rebecca Carroll, 02/13/20
I va,
1,20
119 J�
x TML 10 A
W,
0!
EASEMENTS C)p ;EC
D- OTKEP THAN C17
rrlo-sE•SHOWN ON THE RCCopo�D
Ab PLAT. ARE NOT SHOWN KREON.
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47 t 72S
( MUNICIPALITY OF ANCHORAGE
DEPARTMENT OF HEALTH & ENVIRONMENTAL PROTECTION
ENVIRONMENTAL ENGINEERING DIVISION
825 L Street- Anchorage, Alaska 99501 Telephone 264-4720
ON-SITE SEWAGE DISPOSAL SYSTEM AND/OR WELL INSPECTION REPORT
NAME IPH°NE
LEGAL DESCRIPTION J
LOCATION NO. OF BEDROOMS~
Materials ~~ ,o. of comoa rtme nt~
~Z M..ufacturer ~HOMEMADE: T~/~ lengt~/~ W,dth
~ Liq. capacity~ ~ ~0in gall°ns iF Inside ~/~ Liquid depth
~ ~ DISTANCE TO: Well Dwelling PERMIT NO.
O Z ~ Manufacturer Material Liquid capacity in gallons
. ~ DISTANCE TO: Well //~ Foundat,on?z, Nearestlot~nk / PERMI~~
~ ~o. oflines~ ~1) ken~thofeachl,ne~o, Totallen,thofl,nes~o, Tr.nch~ ~ ,riches D,stanc. bet~eenl,ne~
~ Too of tile to~oo~finish ~rade ~ Material boneath tile~ ~ ~ inches Total effoctive~oabsor~[on~ area
ken,th ~idth De~th P~MIT ~0.
~ ~ Type of crib Crib diameter Crib depth Total effective absorption area
~ Well Building foundation Nearest lot line
~ DISTANCE TO:
~ Class ~, Depth ~ ~ Driller~o~,~ ~0~ Distancetolot~/~line PERMITNO.
~ Building foundation Sewer line Septic tank / Absorption area(s)
~ D~STANCE TO: /2 4 ~+ /~ /~0 //~
OTHER
PIPE MATERIALS
C.O To ~.F;~I~ /P~/,~ ~ ~.
SOl L TEST RATING~
iNSTALLER
~. . ,..:.:.,.:.:...~, ~. .~ ~ ~' xx~'
APPR'~~~~ DATE LEGAL
72-013 (Rev. 3/78)
DEPAR]MEN'T' OF HEALTH AND ENVIFR[]NMENTAL PROTECTION
825 L STREiET, ANCHORAGE, AK 99501
26.4.-.4720
CI INt ...... S ][ '-IF' E; SEE I~,1EiE:: R F' EE: F;~ i'd I 1-'
F'ERMIT NIl:
DATE ISSUED:
850566
09 / 05 / 85
AF:'PL i CANT:
ADDRESS:
COh-t'i'ACT PHONE;:
BRUCE AND CHERYL WEBB
..:,9.-. 1 ADITAK BAY
ANCHORAGE, AK 99502
56:1- 5131
L.I::.U,d .... DESCR i F':
L.. 0 T S I Z lei:
MAX BEDF~OOMS:
StJBDIVISION: CL. EARVIEW
SECTION: 24 TOWNSHIP:
1.33A (SQ.F'T. OR ACRES)
4.
LOT: 1'7
12N RANGE: :].;W
BLOCK: NA '
ListecJ below are the options available 'Lo you in designing ¥'oup septic:
system. Choose the option that best £its youp site.
DEF'TH'TO PIPE BOT']"OM (FT.) 4.0
GF;,'AVEL DEF:'TH (F:T,) 5.0
]"OTAL DEPTH (Fl'.) 9.0
GRAVEl.... WID'I"H (FT.) 2.5
GRAVEL LENGTH (F'I".) 34.0
bR~.vEL V[.L..UME (CLJ YDS ) 1'7.~
T'ANK SIZE (GALS) ].,25().0 **
S[]]:L IRA'TING (SQ.FT'. /BR) 85
4.0 4 ,. 0
0.5 3.5
4.5 7.5
6.0 5.0
· -.' (1) 37. ()
9. () .27.5
"~"'") 0 '~'~ 1~ ~;~..
85 85
· ~-* "I"ANK MUST HAVE: AT LEAS] .... f'WO C[")IdlZ'AR'I-ldENTS
c:ert, if'y t. hat:
1. I am familiaP wit. In the r'equir'ements for on-site sewePs and wells as set
forth by the Municipality of' AnchoPa,ge (MOA) and the State of Alaska,
2. I will install 'Lhe system in accor-dar, ce with all MOA codes and PegLtlations~
and in cc)mpliance with the design cr. itePia of this pePmit.
3., I will adher'e to all MOA and State of Alaska r, equir'ements fop the set. back
distances fPom any existing well, wastewateP disposal system or public
sewePage system on this OF' any adjac:ent OF' neapby lot.
4. t Ltnders'Land that this pePmit is valid fop a maximum of 4 bedPooms and
any enlaPgement wil]. Pequir'e an additional pePmi{.
A L. IF'T STATION IS INSTALL. ED IN AN AREA COVERED BY MOA BUILDING ~ODES,
I"HEN (1) AN ELECTRICAL PERMIT AND INSPECTION MUST BE OBTAINED; (2) AS-BUII_.TS
WII.._L NOT BE APF'F~E)VED WITHe)UT AN ELECTRICAL INSPECTION REPORT; AND (3) THE
tEL_ECTF;f]]CAL. WORK MUST BE DONE BY A L..ICENSED ELEC]"RICIAN.
APF:'L.ICANT': BRUCIE AND CHERYL WEBD
, ............................. : .............. , ..... ...... _.__.__:...__ ........
~-- KL,'ITT
£L, 1£'2~'
Z.o'T /~,
/HUNI~/P4~/TYD£PI': OF 0~. 4NCHo
H ~ L TH
ENVIRo/"!M£NT,4L ',O~OrEcTio
k L: ~ 1 (? 1986'
· ~- ~--~_ ~-
As-Buil~ 8u~ey
I hereby certify, that I have surveyed Lot 17, ~ t~ ~.~
C1earview Subdivision. Anchorage. A1aska. and ~~.~.f}(~
~- - · ' ' · - ' n ~e ~-~'-~'"' '".'~
~h~ ~he ~mgrovemen~s sx~u~ed ~hereo
within the Proper~ ~ines and do not over~ag ~"~TH~
o= encroach on ~e .=o.~-~ ~y~n~ ~j~o~n~ ~.y.:..?y.~.C;).....;~."
there~o~ ~hat no, imOrovements on property
lying ad~ac:en~ thereto encroach' on the Drem--
xses ~n oues~zon and that there ~.re no.
ways. transm~sszon lznes, or other vzszble $?;~-. ....~'~
PERFORMED FOR:
LEGAL DESCRIPTION:
MUNICIPALITY OF ANCHORAGE
DEPARTMENT OF HEALTH AND ENVIRONMENTAL PROTECTION
8;25 L. Street. Anchorage, Alaska 99501 264-4720
SOILS LOG - PERCOLATION TEST
SOILS LOG
r' ce
DATE PERFORMED:
[] PERCOLATION
TEST
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
COMMENTS
SLOPE
SITE PLAN
WAS GROUND WATER S
ENCOUNTERED? ~,~0 L
O
P
E
IF YES. AT WHAT
DEPTH7
Reading Date Gross Net Depth to Net
Time Time Water Drop
PERCOLATION RATE (minutes/inch)
TEST RUN BETWEEN FT AND ~ FT
PERFORMED BY:
CERTIFIED BY:
72-008 (6/79)
BOX ~it~(~, ,~TAR ~OL'TP- A A~"CIIORAGE, ALASKA ~O~
SiX II'iCh WATER WELL DRILLED AND CASED OUT TO THE DEPTH OF
DRILLED aT ThE raTE Of ~27.00 PEr FOOt.
PROPERTY OWNER
87 ~.
LOCATION OF WELL SITe
WeLL LOG:
·
1/2 Ho,toe Su, l.,'nm,~.LbJ..e..~u~p..,h, au.J~ he.
$21.00 p_~ /J: x 87 /.,t.: g1827.00
COST INCLUDES ALL LABOR AND MATERIAL FOR COMPLETION OF SAid DrILLiNG.
WRITE CHECK PAYABLE TO RAMPART DRiLlING WORKS FOR THE SUM OF
DATE.
fl1827.oo
SERVICE CHARGEOF 1~% PER MONTH WILL BE ASSESSED ON PAST DUE ACCOUNTS.
DEF:'ARTMENT OF' I--IEALT'H AND ENVtI:~[)NMENT'AI._ PROTE~[]TION
1:325 L STREET, ANCHORAGE, AK 99501
264-4720
~3 F~ --- S :]: ""r E W E.] L_ L. F' E:Z F~,". tl I -'IF
PERM I 'T' IqO:
][)ATEE IS;SUED:
850553
08 / :'":',O/85
AF'PL I CANT:
ADDRESS: ,
CONTACT F'HONE:
BRUCE & SHERII- WEBB
3921 ALITAK BAY CIR
ANCHORAGE, AK 99502
561-8182
L. EGAL DESCRIP:
I..OT SIZE:
SUBDIVISION: CLEARVIEW
SECTION: 24 TOWNSHIP:
49435 (SQ.F]'. [IR ACRES)
LOT: 17 BLOCK: NA
12N RANGE: 3W
i certi~'y that:
1. I am familiar with the requirements ¢o~ on-site sewers and wells as set
~orth by the Municipality o~ AnchoPage (MOA) and the State oF Alaska.
2. I will install the system in accordance with all MOA codes and regulat:ions,
and in compliance with the design criteria o~ this per'mit.
3. I will adhere to all MOA and State o£ Alaska requirements Fo~ the set. back
distances From any existing well, wastewater disposal system of public
sewer-age system on this or any adjacent or nearby lot.
SIGNED DATE:
APPLICANT: BRL~& SHERIL WEBB
REPLY
SIGNED
J
~t~o---~-~® 4S 472
SEND PARTS I AND 3 INTACT -
PART 3 WILL BE RETURNED WITH REPI. Y.
POLY PAK (50 SETS) 4P472
DETACH AND FILE FOR FOLLOW-UP
MUNICIPALITY OF ANCHORAGE
DEPARTMENT OF HEALTH & HUMAN SERVICES
Division of Environmental Services
On-Site Services Section
P.O. Box 196650 Anchorage, Alaska 99519-6650
343-4744
Parcel I.D.
CERTIFICATE OF HEALTH AUTHORITY
APPROVAL FOR A SINGLE FAMILY DWELLING
Z~(~- ,~--G HAA# i~A
GENERAL INFORMATION
Complete legal description
Location (site address or directions)
Property owner~Tz~-'~'~ .~-~-d~ -~c~,,~ L
Mailing address ~'~-~( ~.. Y-,c~,-r--~, ~-~ ~
Lending agency
Day phone
~-- ~ .~?~
Day phone
Mailing address
Agent
Address
Day phone
Unless otherwise requested, HAA will be held for pickup.
2. NUMBER OF BEDROOMS:
3. TYPE OF WATER SUPPLY:
NOTE:
Individual well ~
Community well
Public water
If community well system, provide written confirmation from State ADEC attest-
ing to the legality and status of system.
TYPE OF WASTEWATER DISPOSAL:
Individual on-site
Holding tank
Community on-site
Public sewer
NOTE:
If community wastewater system, provide written confirmation from State ADEC
attesting to the legality and status of system.
72-025 iRev. 1t91) Front MOA #21
STATEMENT OF INSPECTION BY ENGINEER
As certified by my seal affixed hereto and as of the validation date shown below, I verify that my
investigation of this Health Authority Approval application shows that the on-site water supply
and/or wastewater disposal system is safe, functional and adequate for the number of bedrooms
and type of structure indicated herein. I further verify that based on the information obtained from
the Municipality of Anchorage files and from my investigation and inspection, the on-site water
supply and/or wastewater disposal system is in compliance with all Municipal and State codes,
ordinances, and regulations in effect on the date of this inspection.
Name of Firm
Address :-~.~
Engineer's sig natu re--~-~-~~
Date ~,'-?- ~E
DHHS SIGNATURE
Approved for /~
Disapproved.
Conditional approval for
bedrooms.
bedrooms, with the following stipulations:
Additional Comments
The Municipality of Anchorage Department of Health and Human Services (DHHS) issues Health Authority
Approval Certificates based only upon the representations given in paragraph 5 above by an independent
professional engineer registered in the State of Alaska. The DH HS does this as a courtesy to purchasers of homes
and their lending institutions in order to satisfy certain federal and state requirements. Employees of DHHS do not
conduct inspections or analyze data before a certificate is issued. The Municipality of Anchorage is not
responsible for errors or omissions in the professional engineer's work.
72q325 (Rev. 1191) Bac~ MOA ¢¢21
Be
Municipality of Anchorage
DEPARTMENT OF HEALTH&HUMAN
SERV,C E E
Environmental Services Division
825"L" Street, Room 502 · Anchorage, Alaska 99501· (907) 343-47,
APR 7 7996
MUnicipality ut Anch
Health Authority Approval Checklist Dept. Health& t4,,"'.._
· '"' ',~. oervicea
Legal Description:
A. WELL DATA
Well type ~ ~ o
Log present (Y/N)
Total depth
Sanitary seal (Y/N)
Parcel I.D.:
If A, B, or C, attach ADEC letter. ADEC water system number
Date completed
Cased to /~ ~ '
Date of test
Static water level
Well production
WATER SAMPLE RESULTS:
Coliform ~ 0 '-
Date of sample: ~ - ~-- ,::?~,
SEPTIC/HOLDING TANK DATA
Date installed c~ -2,~-~_~ Tank size
Foundation cleanout (Y/N)
Date of Pumping q
ABSORPTION FIELD DATA
Date installed c~ _ z s--
Length ~4 c>~ Width
Effective absorption area
e. ~-- ~:>-u 11 ~ / 9 ~,.~
Casing height (above ground)
Wires properly protected (Y/N)
FROM WELL LOG AT INSPECTION
cC- II-~'- al--g-96,
g.p.m. ~- - ~- g.p.m.
Nitrate [° [ ~ Other bacteria
Collected by:
! ~ Number of Compartments ~__ Cleanouts (Y/N). ~
Depression (Y/N) ~D High water alarm (Y/N) ~2 ( ~
Pumper
Soil rating (g.p.d./ft2 o~ ~
3 ' Gravel thickness below pipe
Monitoring Tube present(y/N)
Date of adequacy test c1-6~- q6 Results (Pass/Fail)
Fluid depth in absorption field before test (in.); o.~" Immediately afierbcx~ gal. water added (in.):
Fluiddepth ~,~' (ins.) Minutes later: -~c~ ~,--~ Absorption rate =C~*~ /qqo g.p.d.
Peroxide treatment (past 12 months) (Y/N) A~ O If yes, give date
System type ~ '-[--
.-q- ~ Total depth q' /
Depression over field (yin}
For q/ bedrooms
Date installed
Manhole/Access (Y/N)
High water alarm level at*
Cycles tested
/q~) / Size in gallons
,~~q~o~ on" level at* "Pump off" level at*
E. SEPARATION DISTANCES
SEPARATION DISTANCES FROM WELL ON LOT TO:
Septic/holding tank on lot /13 [
; On adjacent lots / c:, c>
Absorption field on lot
; On adjacent lots
Public sewer main
Public sewer manhole/cleanout ~ [A
Sewer/septic service line /c> c> ~c
Lift station Aa { ~
SEPARATION DISTANCES FROM SEPTIC/HOLDING TANK ON LOT TO:
Building foundation -~z ~ x Property line / C~ ~ Absorption field ~ 2 t
Water main/service line .~'c, q' .Surface water/drainage / oo+ Wells on adjacent lots
SEPARATION DISTANCE FROM ABSORPTION FIELD ON LOT TO:
Building foundation ~ 7__
Property Line / 04. Water main/service line
Surface water
Driveway, parking/vehicle storage area
Curtain drain "~(~'
Wells on adjacent lots
ENGINEER'S CERTIFICATION
I certify that I have determined thru field inspections and review ofMunicipai recor.~:{f~t'~}~v~Y~'tetns are
in conformance with MOA ~ ~idelines in effect on this date. ~ c,~ '-.,e,'~ , .~, .c.:..~
Date of Payment
Receipt Number
Rev. 8/95 OSS: haa.wk.doc
Waiver Fee $
Date of Payment
Receipt Number
14:09 CT~E ESI RNCHORtqGE ~ 98? 2?2 82:18 N0.947 1~03
CT&E Environmental Services Inc.
Laboratory Division ..............................................
Laboratory Analysis Report
CT&E Ref.#
Client Sample II)
Matrix
961228.9705
OUTSIDE TAP J 1228-01
Drinking Water
Sample Remarks:
Collected Date 04t07/96
Technical Director
Parameter Ree~lt$ QC PQL Unite Method Al{owab[e prep Anatysi$ Inlt
Ouat t~mita Oete oate
Nitrete-g 1.t8 0,100 ~g/L EPA 353.2 04/09~6 04/09196 BM~
200 W. Potter Drive, Anchorage, AK 99518-1 605 .- Tel: (907) 562-2343 Fax: (907) 561-5301
31 BO Peger Road, Fairbanks, AK 81)709-5471 -- Tel: (907) 474-8656 Fax; (907) 474-9685
ENVIRONMENTAL FAClLITi:ES IN ALASKA. CALIFORNIA. t::LORIDA. ILLINOIS. MARYLAND, MICHIGAN, MISSOURI, NEW JERSEY, OHIO, WEST VIRGINIA
MUNICIPALITY OF ANCHORAGE
DEPARTMENT OF HEALTH & HUMAN SERVICES
Division of Environmental Services
On-Site Services Section
P.O. Box 196650 Anchorage, Alaska 99519-6650
343-4744
Parcel I.D. #
CERTIFICATE OF HEALTH AUTHORITY
APPROVAL FOR A SINGLE FAMILY DWELLING
1. GENERAL INFORMATION
Complete legal description Lot 17; Clearview Subdivision
Location (site address or directions) 7851 E. Klatt Road, Anchoraqe
Property owner Karen and Bob Dick Day phone 345-3468
Mailing address 7851 East Klatt Road, Anchoraqe, Alaska 99516
Lending agency
Mailing address
Day phone
Agent Susan Peacock / JACK WHITE COMPANY
Unless otherwise requested, HAA willbe held forpickup.
NUMBER OF BEDROOMS: 4 ~
TYPE OF WATER SUPPLY:
NOTE:
Day phone 563-5500
Individual well ×xx
Community well
Public water
If community well system, provide written confirmation from State ADEC attest-
ing to the legality and status of system.
4. TYPE OF WASTEWATER DISPOSAL:
NOTE:
Individual on-site
Holding tank
Community on-site
Public sewer
If community wastewater system, provide written confirmation from State ADEC
attesting to the legality and status of system.
72-025 (Rev. 1/91) Front MOA #21
5. STATEMENT OF INSPECTION BY ENGINEER
As certified by my seal affixed hereto and as of the validation date shown below, I verify that my
investigation of this Health Authority Approval application shows that the on-site water supply
and/or wastewater disposal system is safe, functional and adequate for the number of bedrooms
and type of structure indicated herein. I further verify that based on the information obtained from
the Municipality of Anchorage files and from my investigation and inspection, the on-site water
supply and/or wastewater disposal system is in compliance with all Municipal and State codes,
ordinances, and regulations in effect on the date of this inspection.
Name of Firm
Address
Engineer's signature
DHHS SIGNATURE
.//~ Approved for
Disapproved.
17034 Eagle River Loop Road No. 204
Phone
bedrooms.
Conditional approval for
bedrooms, with the following stipulations:
Additional Comments
By: Date /
The Municipality of Anchorage Department of Health and Human Services (DHHS) issues Health Authority
Approval Certificates based only upon the representations given in paragraph 5 above by an independent
professional engineer registered in the State of Alaska. The DHHS does this as a courtesy to purchasers of homes
and their lending institutions in order to satisfy certain federal and state requirements. Employees of DHHS do not
conduct inspections or analyze data before a certificate is issued. The Municipality of Anchorage is not
responsible for errors or omissions in the professional engineer's work.
72-025 (Rev. 1/91) Bact( MOA #21
Municipality of Anchorage
Department of Health & Human Services
HEALTH AUTHORITY APPROVAL CHECKLIST
Legal Description: LOT 17 C.~.EII~VlE~J
A. WELL DATA
Well type
Log present ~.0N)
Total depth
If A, B, or C, attach ADEC letter.
Date completed
Cased to ,?Z /
ADEC water system number
(~//I/~.Y" D ril ler/I~ ,qr~l i:)j~T
Casing height
Sanitary seal (~/N)
Date of test
Static water level
Well flow
Pump level
Wires properly protected ~.~N) ~'..~ J
FROM WELL LOG
SEPARATION DISTANCES FROM WELL TO:
Septic/h~Jia~-tank on lot //
Absorption field on lot /~'
Public sewer main ,~O/,,/E PIZ.E.f&tJT
Sewer service line
; On adjacent lots
; On adjacent lots
Public sewer manhole/cleanout
Petroleum tank AJOA)~'
AT INSPECTION ~ ~
~>
g'P'~ ~ ~ >
??, z
/~o ~ z
WATER SAMPLE RESULTS:
Co,form O//OO r.g.
Date of sample: i/t~/~3
Nitrate ~
~'/[?/~J~ Collected by:
Other bacteria
B. SEPTICfI~II~M~IM~PTANK DATA
Date installed q/ZS'
Cleanouts~N)
High water alarm (Y~ ,/JO
Date of pumping /;~/1'?/
Tank size [~5"0 ~ Compartments
Foundation cleanout (~1) ff~-,.C ~ Depression (Y/~ ,4)0
Alarm tested (Y/N)
Pumper A+ .IJ, Ot/1g EE~ViC,~5;
SEPARATION DISTANCES FROM SEPTIC/~TANK TO:
Well(s) on lot /I.? ' On adjacent lots
To property line_ ~' ~h Absorption field
Surface water/drainage
Foundation '7/"
Water main/service line
72-026 (Rev. 7/91) Front CONTINUED ON BACK PAGE
Date insta~ Manufacturer
Manhole/Access (Y/N)
Size in gallons
Vent(Y/N) "P~t&
~ on lot On adjacent lots Surface water '""-,.,
D. ABSORPTION FIELD DATA
Date installed
Length ~k~/ - Width -~ /
Total absorption area 400 ~r' --
Depression over field (Y/~
Results ~/fail)
Peroxide treatment (past 12 months) (Y/~
Soil rating o~5" ~'//~ System type
Gravel thickness --~' / J Total depth
Cleanouts present ~Y.,~N) ~/ES ~
Date of adequacy test J/~/~ ~ --
for + -- bedrooms
/,)oW~ /~'/,J0¢/J If yes, give date
SEPARATION DISTANCE FROM ABSORPTION FIELD TO:
Well on lot 1|~' /
To building foundation
On adjacent lots ,~'/4-
On adjacentlots /~:~ C/. Propertyline
To existing or abandoned system on lot
Cutbank ~.)~E /'~,¢-EfC'/J~'Water main/service line
Surface water
Driveway, parking/vehicle storage area
Curtain drain
E. ENGINEER'S CERTIFICATION
I certify that I have checked, verified, or conformed to all MOA and HAA guidelines in effe_.~l~,~cZate of this inspection.
S & S ENGINEERING
17034 Eagle River L~p Road No.
E.ginee ', Name ......
Date ~- ~-~ '
HAA Fee $ /~'0
Date of Payment
Receipt Number
72-026 (Rev, 3/91) Back MOA 21
Waiver Fee: $
~//~.¢~ Date of Payment
Receipt Number
%,~ / ,-//
CHEMICAL & GEOLOGICAL LABORATORY
A DIVISION OF COMMERCIAL TESTING & ENGINEERING CO.
5633 B STREET ANCHORAGE, ALASKA 99518 TELEPHONE (907) 562-2343
ANALYSIS RESULTS for INVOICE t 61768
Chea].ab Ref.t 92.6907 Sample t i Matrix:
WATER
FAX: (907) 561-5301
Client Sample ID : LZ? CLEARVIEW S/D Client Name :S & S ENGINEERING
PWSID : UA Client Acct :SNSENGP
Collected : 12/17/92 ~ 10:55 hrs. BPO$ :
Received : 12/18/92 ~ 14:45 hrs. Req$ :
?zeserved with : Ozdezed By :R. SHAFER
POS :NONE RECEIVED
Analysis Completed : 12/21/92 Send Repozts to:
Laboratory Supervisor ~STEPHEN C. EDE I)S & S ENGINEERING
Released By : '~,~ 2)
mmmmmmmmmmmmmmmmmmmmm{mmmmmmmm{{mmmm{mmmmmmmmmm{mmmmmmmmmm{mmmmmmmmmmmmmm{mmmmmmmmmmmmmmmmmmmmmmmmmm{mmmmmmmm{mmmmmmmmmmmmmmmmmmmmmm
Parameter Results Umts Method Allowable Limits
NITRATE-N 1.09 n~/1 EPA 353.2/300.0 10
Sample ROUTINE SAId~LE COLLECTED BY: S.S,
Remarks:
I Tests Per£ormed ' See Special Instructions Above UA-Unavailable
ND- None Detected *' See Sample Remarks Above
NA- Not Analyzed LT-Less Than, GT-Greatez Than
Member of the SGS Group (Socib,~ G~n(~rale de Surveillance)
/IUNICIPALITY OF ANCHORAGE
DEPARTMENT OF HEALTH AND ENVIRONMENTAL PROTCc;TION
DIVISION OF ENVIRONMENTAL HEALTH
CERTIFICATE OF INSPECTION FOR HEALTH AUTHORITY APPROVAL
OF ON-SITE SEWER AND WATER FACILITY
264-4720
Application Date
GENERAL INFORMATION
(a) Legal De.~scription (include lot, block, subdivision, section, township, range)
Location (address or directions) /.., '
(b) Applicant Name"~V''-'~¢~' "~' (,~--~5¢5 .Telephone: Home ~'-Z~ Business
Applicant Address '~--~"~ ~-.L/~
(c) Applicant is (check one): Lending Institution []; Owner/builder I~; Buyer []; Other [] (explain);
(d) Lending Institution
Address
(e) Real Estate Company and Agent
Address
Telephone
Telephone
(f)
Mail the HAA to the following address:
z-I Az-/TP¢-- lZ:,/Y'¢
TYPE OF RESIDENCE
Single-Family I~ Multi-Family []
Number of Bedrooms ~
Other
3. WATER SUPPLY
Individual Well [~ Community [] Public []
Note: if community well system, must have written confirmation from the State Department of Environmental Conservation
attesting to the legality and status.
4. SEWAGE DISPOSAL
Onsite ~ Public [] Community [] Holding Tank []
Note: If community well system, must have written confirmation from the State Department of Environmental Conservation
attesting to the legality and status.
72-025 (11/8,4)
Page 1 of 2
ENGINEERING FIRM PROVIDING INSPECTIONS, TESTS, FILE SEARCH, D~ I'A AND INFORMATION~~
As certified by my seal affixed hereto and as of the validation date shown below, I verify that ~ion of thi~
Authority Approval shows that the on-site water supply and/or wastewater disposal system's safe, andl adequate
for the number of bedrooms and type of structure indicated herein. I further verify that based on the information obtained
from the Municipality of Anchorage files and from my investigation and inspection, the on-site water supply and/or
wastewater disposal system is in compliance with all MuniciPal and State codes, ordinances, and regulations in effect on
the date of this inspection.
Name of Firm ~.~u,..%/~ ~--¢~j /' ,u ~ ~- ~ ~ Telephone ~ ~" -- ~'~ '~ --~
Address ~ ~ ~ ~ Z ~ ~Z~a/ ~ ~
Date
Approved Disapprorved Conditional
Terms of Conditional Approval
CAUTION
The Muncipality of Anchorage Department of Health and Environmental Protection (DHEP) issues Health Authority
Approval certificates based solely upon the representations given in paragraph 5 above by an independent professional
engineer registered in the State of Alaska. The DHEP does this as a courtesy to purchasers of homes and their lending
institutions in order to satisfy certain federal and state requirements. Employees of DHEP do not conduct inspections or
analyze data before a certificate is issued. The Municipality of Anchorage is not responsible for errors or omissions in the
professional engineer's work.
Page 2 of 2
72-025 (11/84)
MUNICIPALITY OF ANCHORAGE (MOA)
HEALTH AlYltiORITY APPROVAL (HAA)
CHECKLIST - FEBRUARY 1984
MUNICiPALiTY OF ANCHORAG,~
DEPT. OF HEALTH &
ENVIRONMENTAL PROTECTION
1 8 1§86
RECEIVED
If A, B, c~ C, D.E.C. Approved(Y/N)
~,////~ ~" Yield
Depth of G~outing
Sanitary Seal on Casing (Y/N)
Depression Around Wellhead (Y/N)
Date Can~ple ted
Pump Set At
?
; On Adjoining Lots AJ ~ ~C
Well Classification
Well Log P~esent (Y/N)
Total Depth ~ ~ / /
, Cased to
!
Static Water Level _~ ~
Casing Height Above Ground /
Electrical Wiring in Conduit
Separation Distances f~cm Well:
T~~oldiP~] Tank on Lot. /
0
2
TO Nearest Edge of Absorption Field on Lot
~/ //g- ; On Adjoining Lots
To Nearest Public Sewer Line /[//,/p'- TO Nearest Public Sewer
Cleanout/Manhole jl//./'~_ TO Nearest Sewer Service Line on LOt
Water Sample Collected ~y ~. ,~,.3 .S/-,. ; Date '~///./~ ~
Water Sample Test Results ,~o /i,~ L~/~J_ ~
CcmTents
B. ~OLDING TANK DATA
Date' Installed ~,~ ~-/~ fi- Size /~ ~'-~
Standpipes (Y/N) ~/ Air-tight Caps (Y/N) y
Depression ove~ T~ank (Y/N) BJ Date Last Pumped
Pumping/Maintenance Contract on File (Y/N) /g//~, fc~ /lJ/ ~
Holding Tank High-Water Alarm (Y/N) ~//~- Temporaz-g Holding Tank' Permit
separation Distances f~om Septic/Holding Tank:
To Water-.Supply Well
To Property Line ~r-O
To Water Main/service Line
course
Comrents
No. of Ccmpartments
Foundation Cleanout
/
TO Building Foundation 7/
To Disposal Field /
To Stream, Pond, Lake, c~ Major Drainage
[Page 1 of 2] 2-15-84
C. ABSORPTION FIELD DATA
Soils Rating in Absorption Strata
Date IP~talled cf/7
Width of Field
Length of Field
Depth of Field
Type of System Design
Square Feet of Absorption A~ea
Depression over Field (Y/N) A3
Results of Last Adequacy Test
SeDaration Distance f~cm Absorption Field:
(.Y/N))/
Gravel Bed Thickness
~f Standpipes P~esent
Date of Last Adequacy Test
To Water-Supply W% 11 //~- ~/-
To Building Foundation ~ ~ ~--
~ot ~ ,//~- , ~ ~oining ~ ~/~
TO Wa~e~ Main/~rvi~ Line ~/~ To ~t~(if ~e~nt)
To Stre~ond~ke/~ ~jo~ ~aina~ C~se ~/~
To ~i~way, Parki~ ~ea, ~ Vehicle St~a~ ~a ~ ~ ~
To ~oper~ ~.ine , ? 5- ~ J-
To Existing or Abandoned System cn
Con~nts
D. LIFT STATION
Date Installed
Size in Gallcns
"Pump On" Level at
HighWaterAlarmLevel at
Tested for
Electrical Codes(Y/N)
Dimensions
Manhole/Access (Y/N)
"Pump Off" Level at
Vent (Y/N)
Pumping Cycles ~k~ing Adequacy Test.
~eets
Con~nts
** Check Permitted Bedrocm Rating Against HAA .~equest **
I certify that I have checked, verified, or conformed to all MOA ~'~C~{~jn effect
on the date of this inspectic~.~ - ? '~'-~-~ ~ '
~~ Date ~// --e, z';' °'
Signed
.'. ...... . ~ ~ /
? ' ..,
,?' ',' ,.. CE-5333
2-15-84